Pratt Medical Center is the oldest and largest multi-specialty group practice in the Fredericksburg, Va., area, with roots dating back to the 1937 merger of five family practice physicians. Now, however, our group faces the very modern challenge of trying to productively manage 1,000 new claims each day.
Facing ever-tightening payer restrictions and a greater number of patients carrying personal liability, we realized a few years ago that our continued success ultimately depends on the ability to do two things: 1) submit clean claims faster, and 2) easily generate reliable business intelligence. Unfortunately, at the time, both goals were hampered by underperforming technology solutions. A perfect example could be found in our denial management efforts.
We knew each billing staff member re-worked about 10-15 denied claims per day. However, our clearinghouse was unable to create basic denial reports - for instance, by provider or CPT code - that would allow front-end alleviation of recurring problems. While the practice management (PM) system we employed at the time included a denial tracking function, the process was so tedious that our staff seldom had enough time to use it. The end result: sub-par denial tracking efforts.
Claims submission suffered similarly. With no upfront notification from our clearinghouse about payer-specific reimbursement restrictions, dirty claims leaked through to payers. We were forced to devote already-stretched staff hours solely toward re-working denials - instead of toward much-desired patient service efforts such as explaining benefits or collecting balances and deductibles. In addition, the need to manually search for patient EOB information made filing secondary and tertiary claims particularly problematic.
It became clear to us that limitations with our existing PM system and clearinghouse were preventing us from accomplishing key business goals. In order to drop our average days in AR, for example, we needed to get claims out the door faster. It was also imperative to keep on top of the ever-growing number of payer edits that make it so difficult to submit clean claims. In addition, because the lean economic times pinched the bottom line, we wanted to do all of this with the same number of billers - or fewer.
Business objectives require new technology solutions
The first step toward achieving our goals involved switching to a new PM system that featured a more open architecture that did not lock us into using proprietary claims processing software. When we subsequently made the decision to look for a new clearinghouse partner, we were free to evaluate all of our options.
I commenced the evaluation process along with the practice IT director, who also serves as chief operating officer. The benefit of such a small search team is that we did not need formal evaluation tools or an involved, committee-driven process. On the other hand, it also meant we did not have the time or resources to devote to vendors who required us to carve out lengthy blocks of time for meetings and demonstrations. Instead, we chose to review vendors who were willing and able to show us their clearinghouse solutions via the Web.
We found these online demonstrations valuable in two ways. First, they revealed each vendor's inherent comfort with Web-based technology. But they also gave us insight into how well each vendor was equipped to assist us, should we need it, through Web-based education.
That was important, because one of our top priorities was to find a clearinghouse that was intuitive and easy to use. We desired simple-to-navigate, self-explanatory interfaces that would allow anyone to step in and perform the duties of any other staff member. Our goal was to find a clearinghouse solution that could help us maintain productivity across-the-board, even in the absence of key staff.